Skin Risk Assessment Form
Roseville Skin Cancer Clinic
Name
*
First Name
Last Name
Email
*
example@example.com
Age
*
Gender at Birth
*
Male
Female
Previous History
Do you have a history of irregular or changing moles (size, shape, colour)?
*
Yes
No
Unsure
Have you ever been diagnosed with cancer including skin cancer?
*
Yes
No
Has anyone in your family had melanoma or other types of skin cancer?
*
Yes
No
Unsure
Sunburns, Tanning and Solarium Use
Have you ever have blistering sunburns, or used tanning beds/solariums?
*
Never
Rarely (a few times in life)
Occassionally (every few years)
Frequently (every summer or regular solarium use)
Medical Background
Do you take medications or have conditions that weaken your immune system? (examples: organ transport, long-term steroids, chemotherapy or immune suppressing medicines)
*
Yes
No
Unsure
Do you have a condition that makes your skin unusually sensitive to sunlight?
*
Yes
No
Unsure
Sun Exposure and Protection
On a typical day, how long are you in the sun between 10am-3pm?
*
<30 mins
30-60 mins
1-3 hrs
> 3hrs
When outdoor, how often do you apply sunscreen?
*
Every 2 hours
Every 2-4 hours
Rarely
Never
When outside, how often do you use protection measures (hat, protective clothing, sunglasses, shade)?
*
Always
Often
Sometimes
Rarely
Skin Type
How many freckles do you have on unexposed areas of your skin?
*
Many
A few
None
What is your natural skin colour (before sun exposure)?
*
Very fair (always burns, never tans)
Fair (usually burns, sometimes tans)
Light-medium (burns occasionally, tans gradually)
Olive-brown (rarely burns, tans easily)
Dark brown-black (never burns)
Reason for Visit
Acknowledgement
This form helps us assess your risk for skin cancer. It does not replace a medical consultation. Please raise any concerns with your doctor during your appointment
*
I understand and agree
Total Risk Score
Risk Band
Triage Recommendation
Submit
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